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目的 探讨理想的全胃切除术后消化道重建方式。方法 对1995－1999年经病理证实行全胃切除术胃癌235例进行回顾性分析。其中，功能性间置空肠代胃术（FJI）78例（33．2％），“P”型Roux-en-Y空肠代胃术（PR）157例（66．8％），随访2年，比较其术后的并发症、Visick指数、体重变化。结果 89％的FJI术后病人的Visick系数为Ⅰ-Ⅱ;PR的Roux-en-Y滞留综合征（RSS）发生率为42．7％。倾倒综合征、返流性食管炎分别为16．7％、26．5％。结论 FJI保持了重建消化道神经－肌肉功能的连续性，恢复食物经过十二指肠通道，对于减少全胃术的并发症、提高生存质量有重要意义，是全胃切除术后理想的消化道重建术式。     

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全胃切除是胃体癌和累及两个分区以上胃癌的首选术式 ,其手术并发症和术后生存质量与消化道的重建方式有关。自 1995年 10月至 1997年 6月 ,我院为 30例胃癌病人施行根治性全胃切除 ,原位十二指肠、部分空肠翻转代胃消化道重建手术 ,获得满意效果 ,报告如下。1　资料与方法1 1　一般资料30例病人中 ,男 18例 ,女 12例。年龄 2 7～ 72岁 ,中位年龄 5 2岁。肿瘤部位 :ＭＡＣ/ＭＣＡ 1例 ,ＭＣ/ＣＭ 5例 ,ＭＡ/ＡＭ 9例 ,Ｍ 13例 ,胃窦及胃体双原发癌 1例 ,残胃癌1例。组织学类型及分级 :30例中 ,高、中、低分化腺癌分别为 5、8、9例 ,粘液腺癌…     

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??Usage of mechanical stapler in digestive tract reconstruction of laparoscopic total gastrectomy MIAO Ru-lin??LI Zi-yu??WANG Yin-kui??et al. Gastrointestinal Cancer Center, Peking University Cancer Hospital &Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China
Corresponding author??LI Zi-yu?? E-mail??ligregory@outlook.com
Abstract Objective To evaluate the safety and effectiveness of mechanical staplers in laparoscopic total gastrectomy. Methods The clinical data of gastric adenocarcinoma patients who received laparoscopic-assisted or totally laparoscopic total gastrectomy in Gastrointestinal Cancer Center Ward I of Peking University Cancer Hospital from March 2012 to April 2016 was collected retrospectively. The clinical pathologic characteristics??operative features and postoperative recovery features were compared between patients with linear stapler (LS) and the ones with circular stapler (CS). Logistic regression was used to identify the risk factors of postoperative complications. Results A total of 72 patients were enrolled in the study with 47 patients in the CS group and 25 patients in the LS group. The difference of age??gender??BMI??tumor size??Lauren classification??differentiation grade??and pathologic stage between the two groups were not significant statistically??P??0.05??. The proportion of patients who received preoperative therapy were lower in the LS group (4.0% vs.27.7%??P=0.026). The difference of surgical time and intraoperative blood loss of OS group and LS group were not significant statistically (median surgical time??247min vs. 258min??median intraoperative blood loss??100mL vs. 50mL). There was no statistical difference in the extent of curative??retrieved lymph node number??and proximal margin distance between the two groups. On postoperative recovery??the first liquid diet time was shorter in the LS group (3.5d vs. 5.0d??P=0.030)??but the postoperative hospital stay??first flatus time??first semi-liquid diet time and first abdominal drainage tube removing time were same statistically between the two groups. The rates of postoperative complications were 25.5% and 32.0% in CS group and LS group (P =0.560)??and no risk factor was identified in regression model. Conclusion For laparoscopic total gastrectomy??mechanical staplers are safe. The surgical time??intraoperative blood loss and postoperative risk of linear stapler are comparable to those of circular stapler??and gastrointestinal function recovery may be faster in linear stapler group.     

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??Comparison of the efficiency between two methods of alimentary tract reconstruction after robot-assisted total gastrectomy for gastric cancer DIAO Yan-qing, WANG Zhi-ming, JIANG Zhi-wei, et al. Research Institute of General Surgery of PLA, Nanjing General Hospital of Nanjing Military Region, Nanjing 210002, China
Corresponding author??JIANG Zhi-wei, E-mail??surgery34@163.com
Abstract Objective To compare the feasibility and difficulty between two methods of alimentary tract reconstruction after robot-assisted total gastrectomy for gastric cancer. Methods From April 2012 to April 2015??57 patients with gastric cancer in Nanjing General Hospital of Nanjing Military Region were enrolled for robot-assisted total gastrectomy and reconstruction of digestive tract??and all the operations were performed by the same surgeons. In 35 patients (group A)??reconstruction of alimentary canal was performed using single needle running by an absorbable suture. In the other 22 patients (group B), it was performed using two needle running by a barbed suture (180 Polyglyconate Absorbable Knotless Wound Closure Device). Several parameters were evaluated and compared in the two groups, such as time of operation, time of anastomosis, length of hospital stay, and the incidence rate of postoperative complications. In addition??the difficulty of anastomosis was assessed by the surgeon. Results All the 57 robot-assisted operations were completed successfully without conversion to open surgery. In group A??the total time of surgery was ??251.3±64.4??min??time of esophagojejunostomy was ??37.8±11.6??min??time of jejunojejunostomy was ??29.4±8.7??min??the time of postoperative hospital were ??5.5±3.7??days. In group B??the total time of surgery was ??192.8±52.9??min??time of esophagojejunostomy was ??18.1±7.9??min??time of jejunojejunostomy was ??14.6±6.3??min??the time of postoperative hospital were ??4.7±4.1?? days. Compared with group A??group B represented reduced difficulty in both operation and cooperation??significantly shorter time of the anastomosis?? surgery and postoperative hospital stay??P??0.05??. Furthermore??in group A there were two patients with anastomotic complications (anastomotic stricture)??but in group B they had declined (2/35 vs.0/22). Conclusion Both two kinds of anastomosis for alimentary canal reconstruction in robotic total gastrectomy are safe and feasible. The use of the barbed suture in totally robotic total gastrectomy would reduce the difficulty of reconstruction of digestive tract and save a lot of time of anastomosis??surgery and postoperative hospital stay.     

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目的 探讨胃癌根治切除手术时是否需要预防性放置腹腔引流管.方法 将2005年7月至2006年6月南京军区南京总医院胃癌手术病人随机分为两组,无腹腔引流组(51例)不放置腹腔引流管,腹腔引流组(49例)常规放置腹腔引流管.两组病人均采用胃癌D2式切除术,使用相同的围手术期处理方法.观察两组术后并发症发生率及术后恢复情况.结果 无腹腔引流组与腹腔引流组相比,术后通气时间、恢复进食时间及术后住院时间差异均无统计学意义.两组术后均无死亡病例,术后并发症发生率差异无统计学意义.结论 择期胃癌根治切除术中不常规预防性地放置腹腔引流管是安全有效的.     

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目的观察腹腔镜胃底折叠抗反流手术联合胃袖状切除术对动物模型的可行性和安全性。方法 2013年12月至2014年5月在柯惠上海临床培训中心及奥林巴斯上海实验室对8只小猪行腹腔镜下保留部分胃底的胃袖状切除术联合食管裂孔疝修补术及不同类型胃底折叠术(包括Nissen、Toupet、Dor胃底折叠术)。记录术中情况、手术步骤、技术难点及注意事项等。结果成功完成小猪腹腔镜胃袖状切除术和食管裂孔疝缝合修补术8次,不同类型胃底折叠术24次,即Nissen胃底折叠术、Toupet胃底折叠及Dor胃底前折叠术各8次。无一例中转开腹,所有实验动物均在手术中生命体征保持平稳,平均手术时间为(120.2±13.7)min,出血量为5~80(35.8±11.1)m L。术中1只发生肝损伤出血,其余均未发生脏器损伤及吻合口漏。手术时间随着训练次数明显缩短。结论腹腔镜胃底折叠抗反流手术联合胃袖状切除术对小猪动物模型安全可行,可为临床医师提供极佳训练机会,有助于缩短学习曲线,可能成为治疗肥胖合并胃食管反流病或食管裂孔疝的新型抗反流手术方法。     

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目的介绍一种全胃切除术改良双贮袋Roux-en-Y吻合消化道重建方式,并与传统袢式吻合和Roux-en-Y吻合的中短期效果进行对比研究。方法 2008年5月至2010年3月河南省肿瘤医院普外科将106例因胃癌行根治性全胃切除术病人,随机分为3组分别接受改良双贮袋Roux-en-Y吻合、袢式吻合和Roux-en-Y吻合3种空肠代胃手术方式。比较3组病人的手术时间、术后并发症、住院总费用和住院时间。并于术后1、6、12个月分别进行胃癌病人生活质量调查问卷(QLQ-STO22)评分。结果改良双贮袋Roux-en-Y吻合在手术时间、术后并发症、住院总费用、住院时间等方面与其他两组比较差异无统计学意义。但生活质量评估(吞咽困难、疼痛、呃逆和饮食受限)明显优于其他两组。结论改良双贮袋Roux-en-Y吻合具有安全、术后生活质量高等优点。     

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上消化道重建是胃切除手术中关键操作步骤之一,但上消化道重建术后并发症规范化防治仍存在诸多问题,上消化道重建术后并发症大多数与吻合技术及围手术期处理有关。严重并发症将增加医疗费用,影响病人预后,甚至产生医患纠纷。因此,临床医师应当充分重视上消化道重建术后并发症的防治。     

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进展期胃下部癌占我国胃癌的主要部分,远端胃大部切除是主要的外科治疗方法之一。消化道重建方式是影响远端胃大部切除术后生存质量的重要因素。传统的重建方式为Billroth Ⅰ式或Billroth Ⅱ式。从保留十二指肠通路或抗胆汁反流角度,重建方式进行了多种改良,包括BillrothⅡ式+Braun吻合、Roux-en-Y吻合术、单管空肠间置、空肠贮袋间置、双通道重建。目前研究结果认为,Roux-en-Y吻合术是改善生存质量、可行性与可推广性均较理想的方式。     

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胃切除术后消化道梗阻并不少见 ,但由于机械性原因引起需要手术治疗者仅占少数。术前恰当的术式选择、必需要考虑以下情况 :(1)上次行胃切除手术的原因 ,是因为良性疾病行胃切除治疗 ,还是因为恶性肿瘤而行手术治疗 ;(2 )上次手术是近端胃切除、远端胃切除或全胃切除或行单纯的胃空肠吻合术 ;(3)胃切除后胃肠重建方式是Ｂ Ⅰ式 ,Ｂ Ⅱ式或Ｒｏｕｘ ｅｎ Ｙ吻合 ;(4 )梗阻的部位 ;(5 )出现梗阻的时间 ;(6 )此次梗阻的性质、原因等。其中最为重要的是胃切除术后消化道梗阻的部位和性质、原因。　　根据梗阻的部位分为输入空肠袢梗阻、吻合口梗…     

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虽然上消化道重建方式多种多样,但目前尚无被公认的最佳重建方式。上消化道重建后,一方面必须控制好并发症的发生率;另一方面要保证病人有满意的营养状态和良好的生存质量。胃癌根治术后的重建方式也是专家们一直讨论和研究的热点,一直受到大家的重视。全胃切除术后,Roux-en-Y吻合是一种简单、并发症少,又能满足功能要求的重建方式。对病期晚、预后差的进展期胃癌病人,Roux-en-Y吻合时不建议附加贮袋,对于良性肿瘤或者早期胃癌,可以附加重建贮袋,以期提高生存质量。远端胃大部切除术后,相对于BillrothⅠ式吻合来说,BillrothⅡ式或Roux-en-Y吻合重建术并发症少、肿瘤复发率低。BillrothⅠ式吻合重建的适用范围较为有限。近端胃大部切除术后,采用食管残胃(管状胃)吻合是较为常见的重建方式。幽门重建的作用还存在一定争议,有待进一步研究。     

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目的：探讨全胃切除术后合理的消化道重建方式。方法 自1996年5月至2001年5月，对106例全胃切除术采用了三种不同的术式，对其手术时间、手术并发症、术后1年饮食状况、消化道症状及营养指标进行对比观察。结果：Orr式空肠食管Roux-en-Y吻合术和P式空肠食管Roux-en-Y吻合术，术后能有效地防止反流性食管炎，明显优于Moynihan式吻合术。Orr式空肠食管Roux-en-Y吻合术和P式空肠食管Roux-en-Y吻合术相比，操作更简单，手术时间短，手术并发症也较少。结论：Orr式空肠食管Roux-en-Y吻合术是胃癌全胃切除后消化道重建较为合适的术式。     

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1　全胃切除术的发展史第1例全胃切除术是由Ｃｏｎｎｏｒ于1884年完成,但没有成功,病人于术后因休克死于手术室。第1例成功的全胃切除术是由德国外科医生Ｓｃｈｌａｔｔｅｒ完成,为56岁的胃癌病人,存活14个月后死于继发肝种植转移。第1例Ｒｏｕｘ-Ｙ式全胃切除术于1908年完成,随后的40年中先后有多位学者报道了多种全胃切除术的技术改进,但由于当时的条件所限,手术死亡率高达40%左右。Ｍｏｒｔｏｎ是首先提倡对可切除的胃癌病人行全胃切除术的外科医生,在他的倡导下,全胃切除在40年代末曾风靡一时,但终因全胃切除术的高死亡率和高并发症发生…     

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??Initial comparative study on laparoscopic adjustable gastric banding and sleeve gastrectomy treatment for morbid obesity patiences ZHOU Yong, LIU Jin-gang, GENG Dong-hua, et al. Shengjing Hospital, China Medical University, Shenyang 110004,China Corresponding author??LIU Jin-gang, E-mail: liujg@sj-hospital.org Abstract Objective To initial contrast the surgical technique of laparoscopic adjustable gastric banding??LAGB??and Laparoscopic sleeve gastrectomy??LSG??, and investigate its efficacy for morbid obesity. Methods Among 23 cases,17 were treated by LAGB and 6 were treated by LSG ,and to be viewed curative effect. Results 23 cases were follow-up over 12 months, All result were effective and no major nutritional deficiencies was found. Conclusion The benefits of LSG is easy operation, hypo-complication and foreign material is not implanted in the body, so we believe LSG is good for carry out. Long-term studies are necessary to confirm which is better.     

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??Clinical analysis of 7 methods of laparoscopic esophagojejunostomy after total gastrectomy WANG Wei, ZHENG Yan-sheng, XIONG Wen-jun, et al. Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
Corresponding author??WAN Jin??E-mail??gdphtcmwanjin@163.com
Abstract Objective To introduce 7 methods of laparoscopic esophagojejunostomy after total gastrectomy. Methods The clinical data of 93 patients with gastric caner underwent totally laparoscopic total gastrectomy and Roux-en-Y esophagojejunostomy from December 2011 to June 2015 in Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine were analyzed retrospectively. There were 5 methods of anvil insertion for circular stapling which containing reverse puncture device??anvil lateral insertion??anvil direct insertion??purse string suture and OrVilTM. For linear stapling??there were two methods namely Overlap and FETE. The operative time??blood loss and morbidity of different methods were reviewed. Results The mean operative time was ??293.7±85.3?? min with a mean esophagojejunostomy time of ??23.0±5.8?? mL. Anvil direct insertion was superior to the time of esophagojejunostomy with a mean esophagojejunostomy time of ??18.2±3.7??min. Intraoperative complication occurred in 4 patients and postoperative complication occurred in 3 patients. They were all cured with conservative methods. No death was recorded. Conclusion The 7 methods of totally laparoscopic esophagojejunostomy after total gastrectomy are safe and feasible.     

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??Clinical study on preoperative oral carbohydrate for patients performed gastric neoplasms resection LU Zheng-hao??ZHANG Wei-han??YANG Kun??et al. Department of Gastrointestinal Surgery, West China Hospital of Sichuan University??Chengdu 610041??China
Corresponding author??HU Jian-kun??E-mail: hujkwch@126.com
Abstract Objective To investigate the safety and efficacy of oral intake of glucose solution before surgery in patients performed resection for gastric neoplasms. Methods The clinical data of 44 patients who underwent resection for gastric neoplasms between January 2012 and May 2012 in the Department of Gastrointestinal Surgery??West China Hospital of Sichuan University were collected. The 44 patients with preoperative oral carbohydrate were assigned to group A??while the other 88 patients (group B) with fasting for 10 hours before operation were matched with those in group A with the ratio of 2??1 by gender??age and type of gastrectomy. The comparison was based on the operative and postoperative measures. Results The operation time and the blood loss did not differ between the two groups??while no regurgitation and pulmonary aspiration of gastric contents occurred in both groups. There was no significant difference in the time to pull gastric tube , catheter and abdominal drain tube??the amount of gastric tube drainage liquids, time to first flatus??time of resume fluids, incidence of operative and nonoperative complication, time of hospital stay between two groups??P>0.05??. Compared to group B??the amount of abdominal drain drainage liquids in group A was smaller??197.3±118.8 mL vs. 269.2±207.3 mL??P=0.019??. Furthermore??No hospital readmission was found in 30 days after operation in two groups. Conclusion The safety of administering preoperative oral carbohydrate fluids is supported. But the benefit of the treatment regimen for contributing to improve early rehabilitation and shorter hospital stays after elective gastric surgery is not superior to traditional preoperative preparation.     

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??Selection and technical points of digestive tract reconstruction after totally laparoscopic total gastrectomy
YU Pei-wu??ZHAO Yong-liang. Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery??Southwest Hospital??the Third Military Medical University??Chongqing 400038??China
Corresponding author??YU Pei-wu??E-mail??yupeiwu01@sina.com
Abstract More and more totally laparoscopic total gastrectomy has been reported. The digestive tract reconstruction after total gastrectomy??especially esophagojejunostomy faces many difficulties. Regarding how to safely reconstruct the digestive tract??surgeons in and abroad have made a lot of exploration??and created a variety of reconstruction methods. However??different reconstruction methods have their own advantages and disadvantages. There is still no consensus on how to choose a proper method.     

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??Controversy and consensus of function preserving gastrectomy ZHAO Gang, XU Jia, WANG Shu-chang.Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
Corresponding author??ZHAO Gang, E-mail??zhaogang
74313@aliyun.com
Abstract With the development of diagnostic techniques and the national health screening programs, early gastric cancer patients can get access to more timely diagnoses with favorable prognoses. Thus, surgeons have paid more attention to function preserving of gastrectomy, aiming to limit the perioperative complications and improve quality of life. Pylorus-preserving gastrectomy is widely used as a function preserving gastrectomy, with lower incidence of dumping syndrome, bile reflux and gallstone. However, gastric stasis is a typical complication. Sentinel node navigation surgery can detect lymph node metastases intraoperatively, which assists to assure optimal radicality in various function preserving gastrectomy.